PRAPARE Round One Train the Trainer Academy PCA/HCCN Case Studies
September 2018 Supported by:
About This Document This document contains information collected during a ten-month national Train the Trainer Academy conducted by NACHC, AAPCHO, and OPCA. The first round of the Train the Trainer Academy included eight Primary Care Associations and/or Health Center Controlled Networks: (1) Arizona Alliance for Community Health Centers, (2) Colorado Community Health Network, (3) Indiana Primary Care Association, (4) Maine Primary Care Association, (5) Massachusetts League of Community Health Center, (6) Minnesota Association of Community Health Centers, (7) North Carolina Community Health Center Association, (8) Washington Association of Community & Migrant Health Centers. Acknowledgements This project was made possible with the generous support from the Kresge Foundation. The PRAPARE project team would like to thank the Kresge Foundation in addition to all of the participants for their dedication to learning with and from one another, and to improving the lives of the patients seen at health centers across the country.
© 2019. National Association of Community Health Centers, Inc. PRAPARE and its resources are proprietary information of NACHC and its partners, intended for use by NACHC, its partners, and authorized recipients. Do not publish, copy, or distribute this information in part of whole without written consent from NACHC. For more information and resources on PRAPARE, visit www.nachc.org/prapare or contact [email protected]. Table of Contents
Title and Acknowledgements…………………………………………………………………………..………….……………1
Table of Contents...... …...2
PRAPARE Training Model/Approached Used to Support PRAPARE Implementation in Health Centers
Arizona Alliance for Community Health Centers’ PRAPARE Training Strategies to Advance Social Determinants of Health Interventions…………………………………………………………………………………………………………………………….3
Minnesota Association of Community Health Centers’ PRAPARE Training Model……………………………………………………………………….……………………………………………………..………..4
Washington Association of Community & Migrant Health Centers’ Training and Support Efforts to Use PRAPARE Data for State Transformation Initiatives……………………………………………………………………………………………………………………………………7
PRAPARE Data Strategy Used to Aggregate, Analyze and Visualize Data
Colorado Community Health Network’s Use of PRAPARE Data Visualization to Inform Population Health Management and Payment Reform Efforts………………………………………………………………………………...... …………………………..…8
Massachusetts League of Community Health Centers Supporting PRAPARE Data Reporting, Aggregation and Analysis…………………………………………………………………………………………………………10
PRAPARE Impact and Sustainability Plans to Highlight Uses of PRAPARE Data and Opportunities to Apply PRAPARE Data
How the Indiana Primary Health Care Association Leveraged Their PRAPARE Efforts to Inform State Social Determinants of Health Efforts………………………………………………………………………………………………………..………..………………....12
North Carolina Community Health Center Association’s Use of PRAPARE to Move Toward Delivery System Transformation……………………………….……………………………………………………….….…14
Maine Primary Care Association’s Specialized Approach to Training and Technical Assistance and Identifying Community Partnerships……………………………………………………………………………………………………...…….………………16
The Arizona Alliance for Community Health Centers (AACHC) worked closely with the Collaborative Venture Network (CVN) to support and provide training and technical support to six participating health centers during the Train the Trainer Academy. To implement PRAPARE, AACHC and CVN hosted monthly training sessions for health center staff for eight months. Trainings were conducted in-person for two to three hours every month and tailored specifically for the Arizona health centers. AACHC and CVN’s training sessions mirrored the PRAPARE Train the Trainer Academy sessions to reflect the discussions shared with NACHC and other participating primary care associations. The training sessions paired with shared learning opportunities to report out their lessons learned and challenges was the most important component for the health centers during the sessions. They also included a thorough PRAPARE overview for health centers at the onset of implementation and specifically on how to utilize the PRAPARE Implementation and Action Toolkit. This allowed more tools, resources, and opportunities for group teamwork with the health centers based on their current level of implementation and next steps.
PCA Benefits of PRAPARE Implementation Next Steps AACHC and CVN saw several benefits in supporting their Because of its involvement with PRAPARE, AACHC health centers to screen for the social determinants of strategized how the PCA could help support health health using PRAPARE, such as: centers’ response to the social determinant needs the potential impact of the social determinants data identified and worked with its health centers to: collected to improve health outcomes for their Participate in an Intimate Personal Violence patients, training of trainers on appropriate interventions the ability to develop and improve appropriate referral and partnerships with services available for the social determinant domestic violence service of health needs identified, agencies through Futures demonstrating the value and effectiveness of health Without Violence centers in meeting the needs of patients with complex Discuss a potential pilot where health centers needs serve as food distribution sites and collaborate staying ahead of the curve of SDH implementation as with the Arizona summer meals program for kids the nation pushes forward in addressing the SDH by to address food insecurity having monthly in-person trainings for 2-3 hours, and Develop a resource to show the different ways establishing a PCA information sharing platform for that data may be utilized post-PRAPARE rollout participating health centers based on current data as a sample Compile the community resource lists from the Best Practices and Lessons Learned health centers to share additional Listening and responding to health center resources/referral agencies to identify gaps in feedback about the trainings presentations resources delivered was the most critical piece in ensuring AACHC and CVN supported their health centers appropriately Connecting with and partnering with two “Be flexible to the varied needs of health centers. respective EHRs that the health centers used was Health centers will be at various levels of readiness and will implement different workflow models, which very valuable so that health centers could can make it challenging to develop training that visualize data collection and reporting meets health centers where they are. However, there possibilities is still value in shared learning to troubleshoot Ensure training discussions were focused on common challenges and to hear tradeoffs of different health centers’ future plans and what they would implementation models as health centers test their workflows.” –AACHC PRAPARE Team do differently in addition to what they have
accomplished
The Minnesota Association of Community Health Centers (MNACHC) worked with the Breakwater Health Network to support their health center members with various PRAPARE implementation and social determinant of health (SDH) data utilization strategies. At the onset of implementation, the Minnesota (MN) PRAPARE team originally planned to use a more structured training model, but they determined that it did not align with the various competing priorities at the different health centers. To begin the restructure of their training model and to promote buy-in and increased motivation amongst the health centers, the MN PRAPARE team hosted an in-person kick- off meeting to discuss the PRAPARE project, review the basics of PRAPARE, assess the health centers’ readiness, and using PRAPARE data for population health management. MNACHC and the Breakwater Health Network also discussed training methodology models and realistic timelines that would work best and efficiently for each individual health center.
After learning more of the needs and expectations of the health centers, the PCA worked with the HCCN to integrate PRAPARE trainings into existing scheduled monthly meetings with the health centers. The health centers received thirty minutes of training based on a newly developed PRAPARE implementation guide. MNACHC designed the implementation guide to be used as a training aid by both its staff as well as a self-guide for health centers. Each monthly meeting reserved time at the end for questions, comments and shared learning of successes and challenges. Every MN health centers received all training materials and resources regardless of their readiness to begin the PRAPARE implementation process.
Successes Leadership buy-in due to the importance of Adapted a PRAPARE Implementation Guide: The collecting SDH data for public quality measure guide included step-by-step instructions for health reporting and transiting to value based payment centers who preferred a self-guided method to begin arrangements PRAPARE implementation. Consistent and ongoing marketing of the PRAPARE tool Challenges and Solutions Being flexible and thoughtful in the PCA Scheduling: Adding PRAPARE meetings to existing approach and always keeping in mind the larger meetings with health centers helped align schedules context of health center circumstances and how while not adding additional time away from work they can use the data Staffing: Providing guidance to health centers on the Tracking and managing the technical right staff to include on PRAPARE implementation infrastructure by the HCCN, who managed the teams loading and implementation of the electronic Other Competing Priorities: HIT implementation, form into the HER funding, and a variety of other barriers (e.g., flu season) stood in the way of PRAPARE Developing Resources for Health Centers implementation. MNACHC worked with participating Developed a new PRAPARE website to host all of the health centers to find a specific time when they could resources: This allowed the health centers to access start with implementation. PRAPARE materials whenever they were ready or had time in their schedules. Resources include MNACHC’s PRAPARE Kick-Off Presentation, materials from a HITEQ Population Health Management Training, ICD- “Meeting health centers where they were was the 10 Z code list for social determinants and many more. one strategy that MNACHC believed was To check out more, the website is instrumental in PRAPARE Implementation. https://mnachc.org/member- Integrating trainings into already existing resources/prapareresources/ meetings was key. Additionally, asking them to be honest about realistic timelines was also helpful, as it provided an opportunity for the staff to be included in the PCA strategic decision-making process.” –MNACHC PRAPARE team
Health Center Perspective: Increased Awareness of Patients Risks Related to SDH
Although many health centers are still in the pilot and preliminary PRAPARE data collection phases, they have already begun performing risk stratification related to chronic disease. For example, one health center pulled data reports on all patients with an HbA1c over 9% and reviewed rates of positive responses, further breaking it down into races. The data showed that uncontrolled diabetic Asian patients were at least 12% more likely to feel stressed than other races.
To respond to the health center staff concerns about not having access to resources to respond to the positive findings, MNACHC and its health centers are considering a partnership with NowPow, as they are interested in working with health centers to integrate PRAPARE into their EHRs and referral systems. In addition, one health center found significant value in adding a question related to their immediate needs at the specific visit, “Do you need help today?” This helped the health center staff prioritize needs and provide behavioral health and/or enabling services the same day of the visit.
Screenshots from the PRAPARE Implementation Guide and PRAPARE website developed by MNACHC.
The PRAPARE Implementation Guide can be found on MNACHC’s PRAPARE website at https://mnachc.org/member-resources/prapare- resources/
As Washington State moves toward 90% implementation of Value Based Payment by 2021 under the APM4 model, Washington Community and Migrant Health Centers (WACMHC) continues to emphasize the importance of collecting and tracking social determinant of health (SDH) data. At the state level, WACMHC hopes to align health centers’ SDH measures with the Department of Health, Health Care Authority, and Managed Care Organizations for several reasons, including: (1) to support payment reform and other health care related policy issues, (2) to better describe state-level population health outcomes, and (3) to advocate for funding of SDH data collection in health centers.
“At the clinic level, WACMHC seeks to support health centers in caring for their patient population through data-informed social interventions to improve clinical outcomes.” To continue the spread and use of PRAPARE, WACMHC is sharing the experiences and lessons learned gained from the PRAPARE Train the Trainer Academy with all state health centers to inform workflow choices, and increase awareness of the PRAPARE tool and available WACMHC implementation training and support efforts.
WACMHC’s Training and Support Efforts WACMHC’s training and support efforts aim to accelerate changes at the health center level, spread PRAPARE or “The PRAPARE Academy has provided a platform to PRAPARE-aligned measures to more patients and health centers, learn from other PCAs’ experiences and a good and use SDH data with other state stakeholders. Specific results introduction to the different EHR templates. Having included: a pre-made, nationally recognized EHR template, Environmental scan of health centers to determine SDH toolkit and other materials available was a huge data collection procedures and data aggregating value added benefit.” – WACMHC PRAPARE systems Academy team Support in developing, tracking, and maintaining referral resource in an in-house database list in a shared were receptive to the survey, felt the “questions were environment important, appropriate and would positively affect their Development of a PRAPARE-aligned screening program health care.” implementation toolkit, specific to WA health centers Next Steps in Using PRAPARE Data for State Initiated exploration of the SDH efforts of state partners and payers Transformation Efforts Continue discussions with state organizations to Washington Health Centers’ Use of PRAPARE align SDH measures Participating health centers in Washington were able to Present PRAPARE Academy experiences and determine the needed capacity to implement PRAPARE environmental scan data in a SDH Roundtable organization-wide, including staffing, funding, and IT support event, including FQHCs, state partners, and necessary for success. With the use of tools such as the 5 Rights payors Framework and WACMHC PRAPARE Crosswalk, health centers Create a transparent PCA data dashboard were able to better understand their capacity needs for including SDH measures to support implementing the PRAPARE survey. transformation Develop PCA capacity to support health centers NeighborCare Health has made significant progress in creating a in creating and sustaining community community referral resources list as well as a Standard partnerships, including tracking referrals to Operating Procedure for updating referrals within the list. Also, resources NeighborCare Health conducted a follow-up survey about the patients’ experiences with PRAPARE and found that patients
The Colorado Community Health Network (CCHN) partnered with Colorado Community Managed Care Network (CCMCN) to implement PRAPARE with three participating health centers. The team consisted of a staff member from CCHN’s quality and policy division and a data analyst and project manager of CCMCN. Staff spent a significant amount of time developing and delivering PRAPARE training curriculum for their health centers after attending PRAPARE Train the Trainer Academy learning sessions. CCHN and CCMCN then hosted an all-clinic PRAPARE discussion to encourage clinics to align behind one population of interest to more easily standardize and analyze PRAPARE data. Due to the alignment between different value-based payment arrangements and other quality initiatives, the group selected patients with uncontrolled diabetes (defined as patients with HcA1c scores greater than nine). CCHN’s future plans include possible statewide target population, particularly related to payment reform and the exploration of opportunities for a referral management system. Curriculum Planning Next Steps: Supporting Health Centers in Data CCMCN and CCHN met with participating health centers to Collection to Further Discussions on Risk Stratification understand and customize best PRAPARE implementation As these health centers progress, additional health centers will strategies for each health center. Implementation strategies join the PRAPARE movement. The plan moving forward is for included: health centers to meet every three months to review PRAPARE Unique visits with care managers to ask the social determinants data and refine the data collection process PRAPARE questions as they share lessons learned. Potential use of tablets for PRAPARE screening Phone call PRAPARE screenings Additionally, CCHN is meeting with Regional Accountable Administering PRAPARE during one-on-one visits Entities (RAEs-Medicaid regional contracts responsible for the with the patient during their regularly scheduled management of the Medicaid behavioral health capitation and appointments aspects of physical health) to share how health centers have CCMCN and CCHN then spent time with each health center applied their social determinants of health data to inform care to develop detailed workflow plans to document how, and population health management. These discussions have when, and who is conducting PRAPARE screening using the been positive to show health center value and influence some strategies health centers identified. REAs to consider PRAPARE as they draft plans for risk stratification of patients for care coordination.
Key Takeaways Colorado’s participation in PRAPARE implementation was Data Speaks Loudly: Investing in a data reporting well timed due to Medicaid changes happening within the software and staff capacity to analyze data makes a state. PRAPARE has allowed the PCA and its health centers to align with SD efforts under payment reform. great impact in engaging leaders and partners to invest in and respond to the social determinant needs found in their communities. CCHN found that visualizing the PRAPARE data collected by their health Successful Data Strategies centers using a dashboard not only cemented the CCMCN serves as the data warehouse for health centers participating health centers’ interest and resolve in and uses Tableau’s Business Intelligence (BI) platform for collecting this information, but it also really helped reporting. In this platform, data can be imported from garner interest from other health centers not various channels including text files and Excel spreadsheets. currently using PRAPARE. Visualizing the data helped Tableau has the ability to display social determinants of clinic staff and leadership see just how complex their health data collected by health centers in a manner that patients were and how the data could be applied to engages clinic leadership to have dynamic conversations inform clinic care, population health management, regarding the impact of social determinants in their and payment reform efforts. community, improvements for workflow implementation, and solutions to implementation challenges and barriers. Create clinic synergy: Aligning behind a goal, metric, This engagement created buy-in from both the executive or population amplifies the collective impact and level teams and the care management teams in value of work across health centers and helps to understanding the importance of the PRAPARE tool. facilitate shared learning across health centers.
Health Center-Level Changes as a Result of PRAPARE Implementation
Pueblo Community Health Center is in a unique situation in Colorado as CCMCN hosts their EHR for them. This means that CCMCN has had access to their data since the beginning of the project and has been working to develop reporting mechanisms with Pueblo’s data. Several months into the Academy, CCMCN met with Pueblo staff, including the care managers responsible for completing the assessment, and showed them their data. CCMCN staff observed that reviewing the data during a formal meeting made care managers feel validated for the work they are doing and gave them a way to message the needs of patients. Additionally, Pueblo has launched a partnership with their county health department to utilize the data in future work together that will be further defined over time.
Metro Community Provider Network (MCPN) has utilized PRAPARE as their initial screening tool by Patient Navigators as one of the ways to determine if a patient needs a referral for care coordination. The Patient Navigators are collocated with the care team and are able to utilize time before and after medical visits in the exam room to complete the screening tool with patients. Based on the results of the screen, they can provide resources that day as needed, and also identify if the patient is in need of more intensive services and assistance, which can be provided by the care coordinators. Additionally, MCPN is working to develop an internal risk-stratification model to identify patients for care coordination. To ensure the stratification accounts for the whole person, they are equally weighing medical diagnosis, behavioral health diagnosis, and social determinants in the stratification model.
Graphics from CCMCN’s Tableau demo to visualize their social determinants data collected by Colorado health centers
Massachusetts League of Community Health Centers (Mass League) worked with both their health centered controlled network (HCCN) and Azara Healthcare to emphasize the need to visualize social determinants of health (SDH) data from PRAPARE at a population level. The HCCN worked with the health centers to map their data into the Azara reporting tool, covered the cost of this mapping, and facilitated the meetings between health centers and Azara. This ensured that developed registries were organized effectively and the most useful information was contained for clinical utility. The team also collaborated to add PRAPARE social determinant information to patient visit planning reports to help staff prepare for visits. Once these tools were developed and used, the Massachusetts PRAPARE team set up various meetings to promote this work by displaying the visualized PRAPARE data and demonstrating how its use could inform care and population health management. Using the aggregated data, Mass League is planning to build a partnership with their Department of Public Health for future funding opportunities.
Successes determine the portion of the population that are Health center buy-in and increased motivation: affected by the SDH elements in PRAPARE. By having The health centers in Massachusetts were already the data elements available, DRVS also allowed the PCA enthusiastic about collecting PRAPARE data, partly to look at the data in different ways, such as seeing the because Massachusetts went live with its first Medicaid relationship between specific diagnoses with specific Accountable Care Organization (ACO) on March 1, SDH. For example, what proportion of patients with a 2018. In this environment, the community health diabetes diagnosis also indicated that they have food centers (CHC) recognized the importance of insecurity needs? These kinds of analyses can help understanding the needs of their population and target the enabling services to maximally benefit the PRAPARE provided an opportunity for them to better patient. In the previous example, a health center could manage those needs. Interest in collecting PRAPARE assign a nutrition counselor to work with the food bank data only increased across health centers as Mass and the patient to address their specific diabetic League was able to visualize PRAPARE data and dietary needs. demonstrate how it could be used. UMass Medical
School also collaborated and provided funding to three 1. Development of an Excel based template when the PRAPARE data was not available in DRVS: health centers to learn more about their specific One Massachusetts health center administered the challenges and successes of implementation. PRAPARE paper tool in an electronic library to people that may or may not become health center patients. This was due to the rural location of the health center. They did not want to include these people in their EHR Approximately 10,000 patients have been because if they were not patients, it would be screened using a modified version of the problematic for the clinical quality measures if they PRAPARE tool from two health center partners were listed in the EHR. and Mass League is continuing to work with several other centers to implement PRAPARE. Mass League’s future goals are to implement PRAPARE in six other CHCs over the coming year and then more every year. In terms of value-add, having the training to implement the PRAPARE tool to each health center Strategies for Aggregating, Reporting, and Using in Massachusetts was very valuable. Based on the numbers of health centers in the HCCN, it was PRAPARE Data from Your Health Centers estimated to a cost of about $292 per health Mapping of the data elements into the Azara DRVS center for the HCCN to be trained on PRAPARE. The reporting tool: cost per health center also could include mapping Working with the Azara DRVS tool, the team used the reimbursement and the administrative time to data in several actionable ways, such as developing coordinate calls, go for in-person visits, etc. registries and patient visit planning tools. The team was also able to aggregate the data using DRVS and
The Mass League HCCN developed an Excel-based tool, which allowed the health center to continue administering the tool at the local library as part of their partnership with a community based organization and still obtain aggregate data. If the people later became patients at the health center, there was a function to look up their PRAPARE questionnaire in the Excel tool and then bring the information over to the EHR.
Challenges and Solutions Additional questions to ask the patients: Many screening questions are asked of patients, such as the PHQ-9, tobacco use, falls risk, etc. The intake process is long and many health centers are wary of asking more questions. Getting them to try it on specific small pockets of the patient populations was the best practice. For example, in one health center, the PCA began by having them administer the PRAPARE questionnaire for new patient physicals at their new location. Once the clinic saw that it was not as bad as they feared, they expanded the group of patients. The eventual goal is now to administer it to all patients annually. Aggregating the data is easy for patients who have the DRVS reporting tool.
Key Takeaways
Emphasize the importance of gathering the data, even if you cannot immediately act upon the needs identified. Obtaining the aggregate population level data is very valuable for prioritizing the SDH needs of all of the patients at the health center in an analytic fashion, rather than only having anecdotal stories to determine where advocacy efforts are needed. Using evidence-based analysis will empower health center staff to target meaningful interventions to have maximal impact on their patients. This is especially true when some of the SDHs may be more subtle or less vocalized at appointments and therefore more likely to be overlooked. Having the actual data that points to a SDH that may have otherwise gone undetected will benefit both the patients and the health center in the long run.
Think outside the box. Administer the PRAPARE tool even when there is no EHR template that can incorporate the answers into your EHR. Using the Excel based tool will allow the health center to obtain aggregate level data and be able to begin to understand the SDH factors at the health center. While less optimal than having the EHR template, it is still better to have an option to aggregate data than not having that option at all. In addition, thinking outside the box opens the door to more options, such as implementing PRAPARE in the dental clinic and at outreach sites.
Think about combining the SDH data with referral registries. One health center that Mass League is working with is combining SDH data elements with their referral registries to see if their referrals are appropriately addressing patient needs. For example, if the patient indicates they have food insecurity needs, the referral registry should show a food bank referral. This is an additional “checks and balances” step in the process, so that caseworkers can double check that appropriate referrals were actually generated in the EHR and can track if the patient completed the referral. Having this extra step of connecting the SDH to the referral type closes the loop of addressing patient needs.
Beginning in 2017, the Indiana Primary Health Care Association (IPHCA) supported three Indiana health centers during the PRAPARE Train the Trainer Academy by providing training and technical assistance, developing materials, and closely monitoring and tracking progress with PRAPARE implementation. Although it required significant staff time early in the implementation process to plan a training curriculum and conduct trainings with their health centers, IPHCA considers this time spent to be valuable due to the long-term impact social determinant of health screening will have on alternate payment models and reimbursements to come in the future. Because of its PRAPARE work, IPHCA is now a leader in its state in regards to social determinants of health and have been able to inform and advance other state social determinant work.
IPHCA’s overall goal with PRAPARE is to demonstrate the value and return on investment of social determinants screening to health center leadership to increase health center capacity to collect and analyze social determinants of health data. To achieve this, IPHCA will continue their efforts in working in partnership with payers in Indiana (specifically Medicaid managed care) to incorporate social determinants of health into performance metrics and reimbursement methods. By working closely with the Indiana Quality Improvement Network (IQIN) and other external stakeholders, IPCA will continue to update key PCA staff during meetings with PRAPARE findings and discuss how PRAPARE informs the work of other departments, such as finance and operations, outreach, clinical quality, and policy and advocacy.
Successes and Lessons Learned Spreading PRAPARE and Leveraging Data Having an in-person kick off for each health center IPHCA has engaged with many state partners and payers to and traveling to the sites to decrease travel time encourage a statewide approach to social determinant for the health centers screening. Examples of these efforts include Continuous planning and strategizing with small Engaging health centers to map social PDSAs determinants data from their EHRs into Azara DRVS One-on-one team meetings with different levels of Hiring a Quality Improvement Coordinator to staff support the spread of PRAPARE Completion of the readiness assessments to Collaborating with Family Social Services provide baseline data for PCA to revise health Administration’s Office of Health Equity, which center’s workflow implementation timeline plans to utilize PRAPARE as standard questions for Shared learning opportunities for health centers by other social service agencies in Indiana providing peer-to-peer mentoring by matching Advising the Indiana State Department of Health experienced health centers using PRAPARE to non- and the State Health Commissioner on the value of experienced health centers PRAPARE Workflow mapping exercise with each health Invited the Indiana Minority Health Coalition to center attend the IPHCA Annual Conference’s PRAPARE session
2-1-1 Partnership and Statewide Dissemination IPHCA collaborates with the Indiana 211 Partnership, Inc. “Be the influence by leading. As early adopters, and the Michiana Health Information Network (MHIN) with PCAs have the opportunity to lead and innovate the goal of screening and referring health center patients with social determinants of health data in your using PRAPRARE to local 2-1-1 affiliates. The 2-1-1 affiliate respective state, which is an impactful way to will the share referral information back to the health influence payers and health systems in a centers to close the referral loop. In return, MHIN will also direction that supports community health centers and improved health outcomes for patients.” – aggregate data to share with local communities in IPHCA Team assessing needs and allocating resources to organizations such as other health centers to address social determinants of health.
IPCA’s PRAPARE workflow mapping and PDSA exercises with each of their participating health centers
Through the participation in the PRAPARE Train the Trainer Academy, the North Carolina Community Health Center Association (NCCHCA) identified numerous opportunities to use lessons learned with PRAPARE implementation and social determinant of health (SDH) data utilization to drive policy and advocacy efforts. North Carolina’s most promising opportunities for delivery transformation and value-based care are related to the state’s Medicaid program transitioning to managed care. NCCHCA has been able to utilize their experience with PRAPARE in discussions with the state and other organizations involved in Medicaid transformation.
NCCHCA plans to leverage their experience in the PRAPARE Academy and existing partnerships with statewide enabling service organizations to serve as content experts for navigating community-based resources, forming community-based partnerships to address SDH needs, and developing user-friendly SDH data collection protocols. In addition, a North Carolina based organization, the Foundation for Health Leadership and Innovation is leading a public-private partnership, along with the NC Department of Health and Human Services (NC DHHS), to create the North Carolina Resource Platform, a robust statewide resource database similar to Aunt Bertha or Healthify, which will be available to anyone in the state. By creating a standard platform, health centers and social service providers across the state will be able to use the same tool for stronger feedback loops on referrals. For more information, please click here.
PRAPARE Training and Support Strategies Strengthening State-Level Partnerships to NCCHCA found the following activities helpful to support their health Support Social Determinant Efforts centers with PRAPARE implementation and responding to SDH needs: NCCHCA found it helpful to develop the following Strategizing messaging around social needs screening and partnerships to support SDH efforts in their state: response activities for various staffing roles at the health Developing partnerships with payers throughout the center (providers, enabling services staff, billing/coding, etc.) state with interest in SDH Identifying workflows for documenting, reviewing, and Forming partnerships and spreading innovative social addressing patient social needs within the EHR and/or care needs intervention programs, such as a SNAP “Double management software Bucks” program that originated in one health center Expanding the “No Wrong Door” implementation and training Tying screening to PCMH standards and exploring approach such that any staff can assist with PRAPARE screening as a part of risk stratification to ensure all Working with clinical and quality improvement staff to patients receive social needs screening regardless of prioritize team-based care staffing models and workflows their payer status Exploring confidentiality, diversity, and cultural competency training for all health center staff to respond to patients’ social Next Steps: Spreading PRAPARE Implementation needs to Other Health Center Members Featuring health center and other safety-net provider success stories with PRAPARE screening at NCCHCA conferences NCCHCA has plans for a nine-month social needs learning collaborative for interested health centers based on their staffing capacity to integrate social needs screening in the EHR.
“A big surprise for us was how many health centers The training will be designed to enable health centers to assess their readiness and strategically outline a have innovative programming going on around SDH plan to integrate PRAPARE social needs screening into that the PCA was not aware of & how health centers organizational workflows. don’t necessarily understand how special these programs are. For example, one of the health centers in the pilot set up a Good Neighbor Fund, in which they can help patients with time-limited “Our biggest lesson learned is the importance of necessary expenditures (i.e., if a patient needs gas persistence. The health center community in North to get to a specialist appointment). NCCHCA is Carolina understands the importance of assessing and thinking through how we can better get information responding to social determinants of health. But, there are from health centers to understand the impact of a lot of other things that are on the priority list. As the their work. –NCCHCA PRAPARE Team PCA, we have to be consistent and persistent in our message so that health centers can stay engaged and make this a part of their practice.” –NCCHCA PRAPARE Team
Health Center-Level Changes as a Result of PRAPARE Implementation
Identification of Champions Each health center has seen new leaders emerge who are champions for PRAPARE implementation. For example, at Gaston Family Health Services (GFHS), a Community Health Worker and Director of Quality and Clinical Informatics have emerged as champions for PRAPARE based on their experience with utilizing PRAPARE with patients. The Program Director has driven a lot of the initial work around PRAPARE. At Caswell Family Medical Centers (CFMC), several champions have emerged. The Clinical Operations Manager has been encouraging nursing staff during implementation and has been a resource for identifying community resources. In addition, the Health Care Informatics Manager has spearheaded much of the health center’s efforts, as well as expressed a desire to get more involved with SDH issues at the state level. In addition, a new staff person has been tasked with participation in the PRAPARE Academy at the health center. It seems that she has felt empowered by their initial success with PRAPARE and was excited to share the results during our peer learning call. These staff were already leaders at their health centers, but they have become champions for social needs screening and response programs.
Identifying Unknown Needs & Changing Perceptions Health center staff report that they have been able to identify needs that the health center was not aware of and that would not have come out during a visit without PRAPARE. “There are things that we have identified that are not captured in a regular visit.” The PRAPARE tool has also “opened the door for the patient to be more comfortable with staff” in some situations. This has sometimes helped to change staff perceptions of a patient. According to one staff person, instead of tagging a patient as non-compliant, the staff have been able to think more critically about something that may be going on in the patient’s life that makes it difficult for them to follow instructions.
Increasing Staff Buy-In One of the health centers indicated that staff buy-in has increased, as staff are able to see the impact of identifying SDH needs and connecting patients to services. Initially, staff were hesitant about adding another task to their plate and burdening the patient with more questions. However, they have quickly been able to see the value of adding the PRAPARE questions, as they have encountered needs they are able to provide resources to address. One staff leader has been very helpful in reminding staff that the PRAPARE tool is not just a set of questions to add, but also a “means of getting somewhere” for the patient and community.
New Services One health center has been able to add new services to address patients’ SDH needs. CFMC has created a food pantry on site around the time of their PRAPARE implementation that employees can donate non-perishable food to. Patients who have emergency food needs and are not able to get to a traditional pantry or other delivery site are able to get food to carry them until they are able to locate other resources.
Community Partnerships Both health centers have been able to refine community resource lists, even prior to PRAPARE implementation. Our pilot sites report that having a robust resource list prior to implementation was seen as essential to health center staff. One health center has noted that they have identified some gaps in community services. For example, their patients were being referred to a community partner that was not able to provide the services the patients needed for various reasons. This has helped identify gaps in resources--even in cases where there may be the perception that there are resources.
The Maine Primary Care Association (MPCA) began working with four health centers to incorporate PRAPARE into the work they were already doing so the health centers would recognize its connection to all that they do. MPCA hopes this work will drive conversations about the impact of social determinants of health on care coordination strategies, outcomes and evaluation strategies to position the health centers for payment models that reflect social need. Based on feedback from the health centers, the MPCA made the decision to provide each health center with a specialized and individualized approach with PRAPARE implementation. The health centers in Maine valued sharing their PRAPARE project planning guides and identified next steps with MPCA, while receiving direct support and insight to push forward their health center’s agenda. While it does require dedicated internal staff time to support health centers with PRAPARE implementation, MPCA realistically evaluated their internal capacities and resources before they began working closely with their health centers in strategically planning training models and workflow integration. To continue and spread the work of the health centers, MPCA will provide ongoing 1:1 support to all health centers and continue deepen relationships with community partners.
PRAPARE Training & Technical Assistance Approach troubleshoot implementation challenges early-on MPCA provided three types of training and technical Involve multiple staff from the PCA to help with this assistance based on health center feedback and time work to ensure the work can easily be sustained even available: if staffing changes. PRAPARE dovetails with their role 1) In-person kick-off meeting and adds value to their work with many staff 2) Monthly 30-minute group calls for shared learning Next Steps: Building Community Connections 3) Onsite individualized technical assistance around Identified Transportation Needs The kick-off meeting focused on developing health center MPCA and several other health organizations started a work plans. The 30-minute group calls were a chance to transportation coalition, which has grown to the point where provide updates PRAPARE implementation at health centers they are organizing a mobility management workshop for all and what they learned. Individualized onsite technical interested state partners. MPCA is gathering a large group of assistance in-between the group calls proved critical to people who care about transportation and are willing to troubleshoot challenges and address issues as they arose. dedicate time to work together and address state- and Training Success: region-wide concerns. One MPCA staff person serves on a Resources provided by the national PRAPARE team linking PRAPARE questions to ICD-10 codes were statewide transportation group coordinated by the Maine helpful for health center data collection Department of Transportation to provide feedback and Health centers appreciated one-on-one time with support on health care related transportation issues. the PCA to work through implementation issues Key Takeaways
Find Other Partners to Help Advance Social “With other initiatives and efforts happening at MPCA, it was hard to dedicate staff time to advance Determinants Work: While there are many things that the work. Being part of the Train the Trainer learning health centers and PCAs can do to address social collaborative helped jump-start these social determinant needs, it is important to identify other determinant of health efforts for us and provided the organizations who can help carry out the work. This opportunity to network and partner with national and way, the burden of addressing social determinants state organizations to keep the work moving forward.” – MPCA team doesn’t solely fall on the PCA or health centers. The Maine PCA found it extremely helpful to participate in the statewide transportation coalitions focused so
Lessons Learned: that they could collaborate with others rather than Health centers had a lot to share on the monthly trying to address transportation needs on their own. group calls such that 30 minutes was not enough Value of One-on-One Technical Assistance: Health
time to share centers appreciate one-on-one time with the PCA to Plan onsite visits earlier in the rollout to work through issues and insight in regards to identifying next steps, either via phone or onsite.